COMPLIANCE WITH THIS DOCUMENT IS MANDATORY

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1 COVER SHEET `NAME OF DOCUMENT TYPE OF DOCUMENT at Shoalhaven Hospital Group Critical Care Procedure DOCUMENT NUMBER DATE OF PUBLICATION February 2018 RISK RATING Medium REVIEW DATE February 2021 FORMER REFERENCE(S) SHG CLIN PRAC 18 EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR Site Manager Shoalhaven Hospital AUTHOR KEY TERMS FUNCTIONAL GROUP OR HUB Dr Adrian Taylor Endocrinologist SDMH Ketoacidosis, blood glucose, Hyperglycaemic Hyperosmolar State, osmolarity, insulin Shoalhaven Hospital NSQHS STANDARD Standard 4 SUMMARY A simple guide to the management of patients with DKA Diabetic Ketoacidosis and HHS Hyperglycaemic Hyperosmolar State COMPLIANCE WITH THIS DOCUMENT IS MANDATORY Feedback about this document can be sent to ISLHD-Policies@health.nsw.gov.au

2 1. POLICY STATEMENT A simple guide to the management of patients with DKA/HHS (previously HONK). This policy is consistent with Emergency Care Institute (ECI) Guidelines for the Management of DKA and HHS in the ED 2. BACKGROUND Definitions DKA: DKA: HHS HONK HHS (HONK): BSL ABG UEC COAGS U/A MSU MCS Diabetic ketoacidosis Blood glucose > 15mmol/l ph < 7.15 Bicarbonate < 15mmol/l Urine ketones +++ Hyperosmolar Hyperglycaemic State (previously HONK). Hyperglycaemic Hyperosmolar non-ketotic coma Blood glucose > 15mmol/L (often >28mmmol/L) ph > 7.3 Bicarbonate (HCO3) >15 Ketones can be present but low No significant acidosis Osmolarity (2x Na + 2x K + glucose + urea) > 320 mosmol/l Blood sugar level Arterial blood gases Urea, electrolytes and creatinine Coagulation Urinalysis mid stream urine microscopy culture sensitivities 3. RESPONSIBILITIES All medical and nursing staff involved in the management of these patients 4. PROCEDURE DKA and HHS are life threatening conditions requiring prompt diagnosis and treatment and should be excluded in all diabetics who are hyperglycaemic, dehydrated, drowsy or vomiting or presenting with infection, abdominal pain, myocardial infarction or stroke. Revision: 3 Trim No. DT17/76844 February 2018 Page 1 of 6

3 4.1 Management First 24 hours Initial management of DKA/HHS is identical. Management must be started in ED without delay and all patients must be transferred to ICU for ongoing management Resuscitation assumed, IV access with 2 lines, monitor Keep patient nil by mouth. Aims replace fluid losses stabilise Blood sugar between mmol/l reverse ketosis correct acidosis Commence IV fluids Investigations Initially - Lab: Blood glucose Full blood count/uec Calcium/Magnesium/Phosphate Osmolality/lipase/ /Coags/ketone Arterial blood gases (ABG) Blood cultures Urine U/A / MCS(MSU) / ketone ECG, CXR, consider arterial access for blood sampling for unstable patients Hourly glucometer readings. After 2 hours: ABG, UEC, and lab blood glucose After 6 hours: ABG, UEC, and lab blood glucose Repeat ABG, UEC, and lab blood glucose 6 hourly until blood gases are normal. 4 hourly blood/urinalysis for ketones If K+ not in normal range then Lab UEC every 2 hours. Repeat ECG at 24 hours. Revision: 3 Trim No. DT17/76844 February 2018 Page 2 of 6

4 4.1.3 Insulin Give fluids Delay in patients with severe hypokalaemia K+ <3.3 If patient is already on a basal bolus insulin regime continue basal insulin dose (insulin glargine: Lantus / Toujeo ; insulin determir: Levemir ) Start a Variable Rate intravenous Insulin Infusion (VRIII) at 5 units per hour (50 units Actrapid in 50 ml 0.9% sodium chloride flush 10 ml of the solution through the tubing before attaching to the patient). Note: in patients with an insulin pump safer to disconnect pump and start IV insulin Hourly blood glucose monitoring check fluid status At 4 hours If no fall in blood glucose increase insulin infusion rate to 10 units per hour. When blood glucose <15 mmol/l reduce insulin infusion to 3 units/hour change IV fluid to 5% Dextrose (see below) Then adjust Insulin Infusion using the following formula: Target blood sugar = mmol/l (in the first 24 hours) GLUCOSE mmol/l < >20 INSULIN IV infusion ml/ hour After 4 hours blood sugar above target range: GLUCOSE mmol/l < >20 INSULIN IV infusion ml/ hour If after a further 2 hours target blood sugar still above target range consult Specialist. Note: check pump connections every hour and document remaining volume Fluids Initially IV 0.9% sodium chloride 2L/first hour (adult) then IV 0.9% sodium chloride mL/h over next 2-4 hours when circulation is stable: 0.45% sodium chloride Rate match with urine output (U/O) ml/h mL/h When blood glucose < 15mmol/l change to 5% dextrose at the same rate. Revision: 3 Trim No. DT17/76844 February 2018 Page 3 of 6

5 DO NOT change back to 0.9% sodium chloride if blood glucose increases above 15 mmol/l Instead increase the insulin IV infusion rate as per Sliding Scale. Use caution in the elderly and in patients with cardiac / renal disease. Reduce fluid infusion rate (ie. 4 litres in 24 hours) and consider CVP monitoring. If initial sodium > 150 mmol/l consult Specialist Potassium Initially No K + in the first litre of sodium chloride 0.9%. Exclude hyperkalaemia Ensure urine output > 30mL per hour then Add KCL to one litre bags of fluid as follows: NB: USE PRELOADED BAG WHERE AVAILABLE. Separate infusion pump may be necessary Serum K + < (4-5) (>5) Potassium chloride nil (mmol/litre) mmol/l replacement fluid or via infusion pump mmol/l in replacement fluid or via infusion pump 20mmol/L in replacement fluid Phosphate and Magnesium If serum phosphate falls below 0.32 mmol/l replace with potassium dihydrogen phosphate 20mmol over 6 hours. If serum magnesium falls below 0.6mmol/l replace with 10mmol over 4 hours Additional measures Sodium bicarbonate: Generally NO - Consider sodium bicarbonate if lifethreatening acidosis (ie. ph < 6.9) has not responded to 2 hours of above management. Consult Specialist prior to administration. May be beneficial if resuscitated with NS and hyperchloraemic acidosis Monitoring ECG monitor, hourly observations, accurate fluid balance, urinary catheter if has not passed urine within 4 hours. Invasive BP monitoring in unstable patients and to aid blood sampling. CVP in elderly/cardiac patients. Revision: 3 Trim No. DT17/76844 February 2018 Page 4 of 6

6 4.1.9 The Recovery Phase Aims: improved blood sugar control ie mmol/l Cautiously reintroduce oral diet (gastroparesis common) with normal insulin regimen. Hourly blood glucose monitoring. Fluids 1L 5% glucose + 20 mmol KCL 8 hourly given by constant infusion consider mechanical pump or paediatric burette drip set. Insulin adjusted Insulin infusion hourly according to sliding scale below. Target blood sugar = 6-11 mmol/l BLOOD GLUCOSE mmol/l < >20 INSULIN IV Infusion mls/hour After 4 hours blood sugar above target range: BLOOD GLUCOSE mmol/l < >20 INSULIN IV Infusion mls/hour If after a further 2 hours target blood sugar still above target range consult Specialist. If blood glucose less than 5 mmol/l despite lowest insulin infusion rate: Do Not Stop Insulin change IV fluid to 10% Dextrose 1L + 20mmol KCL at 125 ml/hr notify Specialist If blood glucose less than 3.5 mmol/l or patient has symptomatic hypoglycaemia (which may occur at normal glucose levels) give oral glucose if tolerating diet and protecting own airway. otherwise give 50% glucose 20 ml IV (ie. if patient nil by mouth/confused) notify Specialist Repeat glucometer reading every 10 minutes and administer glucose as above until blood glucose greater than 5mmol/L and patient asymptomatic. Revision: 3 Trim No. DT17/76844 February 2018 Page 5 of 6

7 5. DOCUMENTATION Medical Record, Fluid Balance Chart, BSL Chart, IV Fluid Order Chart, Medication Chart, extra charts as required by specific monitoring. Note insulin infusion to be documented on IV fluid order chart. 6. AUDIT Nil 7. REFERENCES Emergency Care Institute Guidelines for the Management of patients with DKA and HHS in the ED Updated June 2016 Joint British Diabetes Societies Inpatient Care Group: Management of Diabetic Ketoacidosis in adults REVISION AND APPROVAL HISTORY Date Revision No. Author and Approval Nov Author: Dr Adrian Taylor Approval: Walter De Ruyter DON SDMH Sept Author/Review: Dr Adrian Taylor Aug 2011 May Author: Review by Adrian Taylor Approval: SH D&T committee Approved for publication by Southern Clinical Council May 2012 Feb Author: Review by Dr Adrian Taylor Approved: Shoalhaven hospitals DTC - August 2017 Draft for Comment December Approved by Chun Yee Tan, Director Clinical Services, SHG January Revision: 3 Trim No. DT17/76844 February 2018 Page 6 of 6